Archive for May, 2007

NEW YORK (Reuters Health) May 21 – Medical residents continue to experience severe sleepiness, despite adhering to the Accreditation Council for Graduate Medical Education (ACGME) guidelines that limit their work hours to not more than 80 hours per week and 24 hours at a stretch, a new study shows.

The finding, reported at the American Thoracic Society’s 103rd International Conference Sunday, may have implications for patient and resident safety, according to clinicians from Baylor College of Medicine in Houston.

They measured objective and subjective sleepiness in 29 medical residents the day before and the day after they were on-call for 24 hours at the hospital’s ICU.

For two nights prior to call, residents slept an average of 7.15 and 7.75 hours; average sleep duration while on call was 2.5 hours. The mean Stanford Sleepiness Score was significantly different between the pre-call and post-call day (1.5 vs 3.15, p The majority of the residents’ post-call sleep latency (time to fall asleep) was in the pathological range (less than 5 minutes).” This degree of sleepiness is seen in medical conditions such as obstructive sleep apnea and narcolepsy, the researcher explained.

Even on the pre-call day, the sleep latency was lower than normal (9 minutes).

“The findings were surprising,” Dr. Reddy noted. “We did not expect the residents to be this sleepy.”

For the most part, scores on reaction time tests and simple motor skills tests showed no difference between pre- and post-call days, with the exception of two tests in which residents unexpectedly showed better performance post-call than pre-call.

“Training program directors and residents need to be aware of residents’ sleepiness,” Dr. Reddy told Reuters Health, “so that adequate rest and supervision during patient care may be provided for sleepy residents.”

“Residents need to take precautions driving back home after a call, like not driving long distances or taking a nap before driving home,” the researcher added.

The impact of the ACGME guidelines has not been well studied, according to the study team. Based on the finding of this single-center study, “a multicenter study should be conducted and, if the findings are similar, then guidelines to cut down the number of hours per week during ICU rotations may be needed,” Dr. Reddy concluded.

There is no doubt that medical residents are sleep deprived, but apparently so are CEO’s, nurses, ambulance drivers, policemen, and factory workers; all of whom apparently get slightly more sleep than the average doctor, according to a sleep survey conducted by Travelodge in the UK. The report said the top 10 most sleep-deprived professions are:

Company directors (averaging 5.9 hours of sleep a night)

Ambulance crew/paramedics (6 hours)

Tradesmen (6 hours) Leisure and hospitality workers (6 hours)

Police officers (6.1 hours)

Factory workers (6.2 hours)

Nurses (6.3 hours)

Engineers (6.3 hours)

Doctors (6.4 hours)

Civil servants (6.4 hours).

While the Baylor study quoted above showed no difference in reaction times and motor skills pre and post-call, other studies have shown that sleep deprivation has a particularly debilitating effect on decision-making processes that depend heavily on emotion.

A study at the Walter Reed Army Institute of Research in Silver Spring, Maryland, US, set up an experiment where active-duty military personnel were presented with a variety of hypothetical dilemmas, first when well rested and later, after staying awake for 53 hours. Situations included complex life-and-death moral quandaries as well as situations without a moral component.

While participants did not become less “moral” when sleep deprived, they did require two seconds longer on average to answer complex moral questions. Questions without a moral component did not take longer to answer after participants were kept awake. According to principal study author Dr. William Killgore, the findings, along with previous brain-imaging studies, suggest that sleep deprivation has a particularly debilitating effect on decision-making processes that depend heavily on emotion. “When people go for more than 24 hours without sleep there are dramatic decreases in brain activity in the prefrontal cortex [the area of the brain involved in processing emotions and decision-making].”

Both studies recommend that further research, including brain imaging, should be conducted as laboratory results do not always translate to real world situations.

Experts urge residents to find healthy ways to both stay awake and go to sleep. Here are some tips they offer to avoid sleep deprivation:

Make sleep a priority. Most adults need seven to nine hours of sleep a night to function optimally.

Experts recommend preparing for a long shift ahead by getting enough sleep the night before. Also, practice healthy sleep habits, such as adopting a pre-sleep routine and avoiding heavy meals or strenuous exercise within three hours before bedtime.

Learn to recognize the signs of fatigue. According to the SAFER program developed by the American Academy of Sleep Medicine, performance starts to decline after about 15 to 16 hours of continued wakefulness. You are also less alert between 6 a.m. and 11 a.m. after being up all night. Red flags include irritability, trouble focusing, and checking and re-checking work.

Give yourself time to recover after call and adapt to new shifts. The SAFER program claims that it takes two nights of extended sleep to restore baseline alertness and recover from on-call sleep loss. It also takes at least a week for circadian rhythms to adjust after switching from a day to a night shift.

Shift forward. If you have to change shifts, try moving forward in the day, from afternoon to night, for example.

Nap strategically. Naps can be effective fatigue-fighters, as long as they’re taken at the right time and don’t last too long. Napping strategies should include “prophylactic” naps before work. If possible, schedule sleep to take advantage of those times in the circadian cycle when you tend to feel the most sleepy. For most people, that means between 3 p.m. and 4 p.m. and in the very early morning, after 3 a.m.—optimal times for a short nap.

If you can’t hit those windows of opportunities, experts recommend napping whenever possible, as some sleep is better than none at all. It’s best to nap in a quiet environment and for no more than 30 minutes to avoid entering a deep sleep. If you need to recover from sleep inertia—a brief period of grogginess that can last between 15 and 30 minutes—a small cup of coffee may help.

Use caffeine wisely, but it may have diuretic effects, and it has a half-life of seven hours. Experts recommend moderate, strategic consumption, while a study in the May 2004 issue of Sleep claimed that frequent, low doses of caffeine (about two ounces of coffee) may be more effective for staying alert than larger, less frequent doses.

A small cup of coffee might help you recover from a nap or to stay awake for the drive home. But drinking large amounts during the day can stop you from getting to sleep later. Obviously, stimulants such as nicotine and alcohol won’t induce sleep.

Be aware of light. Bright light can cue the brain to stay awake, so get as much light exposure as possible to stay alert. Conversely, wearing dark glasses can help you avoid being stimulated by light during the drive home.

Don’t drive while drowsy. Getting a ride is the best solution, but if that’s not possible, take a nap first or drink coffee. Pull over and take a nap if necessary.

Get educated. The ACGME requires hospitals to provide education on sleep deprivation and fatigue.

The biggest hurdle to be faced may be the culture of medical residency itself. Sleeplessness is viewed as a “rite of passage” and a resident or intern may be hesitant to ask for help for fear of being viewed as “weak” or lazy. The ACGME and ACP are to be credited with addressing this problem, although far more needs to be done.

Is all of this
sorrow? I don’t know.
I stood in the cemetery dressed in
the camouflage clothes of a living man: brown pants
and a shirt yellow as the sun.

Cemeteries are cheap; they don’t ask for much.
Even the wastebaskets are small, made for holding
tissue paper
that wrapped flowers from the store.
Cemeteries are a polite and disciplined thing.
“I Shall never forget you,” in French
on a little ceramic plaque.
I don’t know who it is that won’t ever forget:
he’s more anonymous than the one who died.

Is all of this sorrow? I guess so.
“May ye find consolation in the building
of the homeland.” But how long
can you go on building the homeland
and not fall behind in the terrible
three-sided race
between consolation and building and death?

Yes, all of this is sorrow. But leave
a little love burning always
like the small bulb in the room of a sleeping baby
that gives him a bit of security and quiet love
though he doesn’t know what the light is
or where it comes from.

“It requires some effort to achieve a happy outlook on life, and most people don’t make it.”
-Author and researcher Gregg Easterbrook

Psychologists have recently handed the keys to happiness to the public, but many people cling to gloomy ways out of habit, experts say.

Polls show Americans are no happier today than they were 50 years ago despite significant increases in prosperity, decreases in crime, cleaner air, larger living quarters and a better overall quality of life.

So what gives?

Happiness is 50 percent genetic, says University of Minnesota researcher David Lykken. What you do with the other half of the challenge depends largely on determination, psychologists agree. As Abraham Lincoln once said, “Most people are as happy as they make up their minds to be.”

What works, and what doesn’t:

Happiness does not come via prescription drugs, although 10 percent of women 18 and older and 4 percent of men take antidepressants, according to the Department of Health and Human Services. Anti-depressants benefit those with mental illness but are no happiness guarantee, researchers say.

Nor will money or prosperity buy happiness for many of us. Money that lifts people out of poverty increases happiness, but after that, the better paychecks stop paying off sense-of-well-being dividends, research shows.

One route to more happiness is called “flow,” an engrossing state that comes during creative or playful activity, psychologist Mihaly Csikszentmihalyi has found. Athletes, musicians, writers, gamers, and religious adherents know the feeling. It comes less from what you’re doing than from how you do it.

Sonja Lyubomirsky of the University of California at Riverside has discovered that the road toward a more satisfying and meaningful life involves a recipe repeated in schools, churches and synagogues. Make lists of things for which you’re grateful in your life, practice random acts of kindness, forgive your enemies, notice life’s small pleasures, take care of your health, practice positive thinking, and invest time and energy into friendships and family.

The happiest people have strong friendships, says Ed Diener, a psychologist University of Illinois. Interestingly his research finds that most people are slightly to moderately happy, not unhappy.

On your own

Some Americans are reluctant to make these changes and remain unmotivated even though our freedom to pursue happiness is written into the preamble of the Declaration of Independence.

Don’t count on the government, for now, Easterbrook says.

Our economy lacks the robustness to sustain policy changes that would bring about more happiness, like reorienting cities to minimize commute times.

“Research shows that people who are grateful, optimistic and forgiving have better experiences with their lives, more happiness, fewer strokes, and higher incomes,” according to Easterbrook. “If it makes world a better place at same time, this is a real bonus.”

Diener has collected specific details on this. People who positively evaluate their well-being on average have stronger immune systems, are better citizens at work, earn more income, have better marriages, are more sociable, and cope better with difficulties.

Unhappy by default

Lethargy holds many people back from doing the things that lead to happiness.

Easterbrook, also a Visiting Fellow at the Brookings Institute, goes back to Freud, who theorized that unhappiness is a default condition because it takes less effort to be unhappy than to be happy.

“If you are looking for something to complain about, you are absolutely certain to find it,” Easterbrook told LiveScience. “It requires some effort to achieve a happy outlook on life, and most people don’t make it. Most people take the path of least resistance. Far too many people today don’t make the steps to make their life more fulfilling one.”